Provider Demographics
NPI:1376978239
Name:CLARK, STANLEY D (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 POPPY DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-5533
Mailing Address - Country:US
Mailing Address - Phone:650-759-0719
Mailing Address - Fax:
Practice Address - Street 1:2501 POPPY DR
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-5533
Practice Address - Country:US
Practice Address - Phone:650-759-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 2524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH 25524OtherCALIFORNIA STATE BOARD OF PHARMACY